“Testing Protocols to Win By”
I have now heard for the last time, “I refer patients out for MRI’s after a course of conservative chiropractic care, prior to considering MRI’s.” That is a great statement for any doctor who has a strong desire for their patient to get hurt, to get sued and eventually lose their license by the state licensure board!!!!
HAVE I GOT YOUR ATTENTION YET?
The necessity for MRI’s are not determined by the amount of conservative care that you render or time that has passed, by any criteria. The referral is determined solely by clinical necessity. Let me give you a typical scenario played out in doctor’s offices nationwide:
“Mrs. Jones, I see you have pain shooting down your arms with concurrent weakness in your arms, as well. I am going to commence a course of conservative chiropractic care and see how you do over the next 4-5 weeks. If you do not respond by then, I will consider referring you for MRI’s.”
Now…Here is what you are really saying to your patient:
“Mrs. Jones, I see you have pain shooting down your arms with concurrent weakness in your arms, as well. I am going to now start introducing high velocity thrusts into your spine on a repetitive basis and hope that I don’t hurt you. I know that if there is a serious disc herniation or other space occupying lesion, I might create a more serious spinal cord condition, cause you to be a paraplegic or quadriplegic, or do something that results in a need for surgery, as a result of what I am going to do to you. It’s OK that I really don’t know what is going on with you because my x-rays don’t show me what is wrong with you and I’ll guess that I can help. BUT…I feel confident that it is a good gamble to repetitively deliver high velocity thrusts into your spine and I am sure that you are happy that I am good at gambling on your health…Let’s get started.”
Isn’t that what you are really telling your patients? Yes or Yes? I don’t get it. Is it because you have bought into the paradigm to create a financial windfall the insurance company has created for themselves? The same insurance company that has convinced you to not take early MRI’s because they don’t want to pay for them, is the same entity that will support you losing your license because you didn’t follow accepted diagnostic testing protocols. Even in managed care, a system designed to take advantage of every patient and doctor, there is a mechanism for getting MRI’s approved from day #1. Use it!!
There is only 1 criteria for ordering an MRI, clinical necessity, not time. If a patient exhibits myelopathic or radiculopathic findings, then an immediate MRI should be considered because chiropractors have a different standard of care than any other health care delivery system. Orthopedist, neurologist, physiatrist and internist will use pain medications, pain injections, rest or physical therapy as their solutions, and if all else fails, recommend a surgical consultation.
Chiropractors, as a rule, will use the adjustment as our primary treatment of choice. This is the correct choice of treatment for the patient, and after 25 years of treating these types of patients I am qualified to make that statement. There is 1 caveat…I will aggressively adjust the patient AFTER I KNOW WHAT I AM TREATING.
As a result of the different approach to the care of our patients, we have very different modalities than the medical community. Therefore, we need a different standard in approaching the care of our patients. The diagnostic modalities are the same, however, the timetable is different. Treating a patient with these types of problems without having a complete and accurate diagnosis is dangerous to the patient because you simply do…not…know.
I worked with a doctor who had a signed release from their patient, to treat them without testing. That doctor had serious licensure issues because there is no piece of paper that exonerates you from protecting the well-being of your patient in the eyes of a licensure board. A standard of care is just that and cannot be deviated from. Again, remember the purpose of a licensure board is to protect the public and your license isn’t a right, such as freedom in the Constitution. It’s a privilege. Therefore, you have very few rights with a licensure board and you must adhere to your state’s standards of care.
Remember, if you hurt someone, you will not feel the repercussions for many years. The patient will first seek medical or surgical intervention, then hire a lawyer to sue you and report you to the state licensure board. It usually takes 3-4 years to get to that point and chances are, you won’t even remember the patient.
The rule of thumb I use to judge a doctor if they are ordering the correct amount of MRI’s for their patients, is 3% of the population weekly. If you are treating 100 patients per week, then 3 patients should be referred for an MRI. I am not talking about only trauma or PI cases. This is for the whole patient population. This number is a rough guideline, and each patient has to be referred based upon the merits of the clinical findings. However, after consulting many offices through the years, this statistic has been relatively accurate.
Will lawyers be happy if you refer their clients for an MRI? The answer is, "WHO CARES?" You do not refer to make a lawyer happy; you do it because it is clinically necessary. If you want a very large personal injury practice, build it through clinical excellence.
The person that will be the most happy, is your patient. Over the years, patients have repeatedly shared with me their joy in having a doctor that was thorough in getting to the cause of their problems. Many shared with me that their previous doctors (orthopedists, neurologists and family doctors) would be very resistant to ordering tests, and they were very upset and frustrated because they were still in pain and no one knew why.
The winning formula is to take a careful history, do a thorough clinical examination, order testing immediately if clinically indicated, and once you know exactly what is wrong with your patient, adjust them. This also necessitates that you are expert in understanding diagnostics at a much higher level, if you are going to use them. You can’t rely solely on the specialists in interpreting the results; it goes back to taking additional coursework, if necessary, to sharpen your clinical skills.